Quote of the Week:

"Recall may be affected by the vividness of information: Is it not easier to remember the story about the emergency transfer for cord prolapse than of the woman who labored for two hours and gave birth gently at home?"

- Sara Wickham

The Art of Midwifery

Alfalfa tablets are an excellent source of micronutrients, and they help a woman who is not getting routine good nutrition.

News Flashes

Researchers collected data on self-reported cigarette use and urine cotinine
concentration from 1583 pregnant smokers at the time of study enrollment--at the
first or second prenatal visit regardless of gestational age--and in the third
trimester. As indicated by urine cotinine measurement, 1349 women were actively
smoking at enrollment and 234 were not. Women who quit smoking before enrollment
and those who quit after enrollment delivered infants with the highest adjusted
mean birth weights (3492 and 3491 g, respectively). Women who reduced their cigarette
use had a mean adjusted infant birth weight 32 g heavier compared with those who
did not change their cigarette use, but the difference was not statistically significant
(p = 0.33). Infant birth weight initially declined sharply as third-trimester
cigarette use increased. However, the decline leveled off at more than eight cigarettes
per day.

- Am J Epidemiol 2001;154:694-701

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Effects of Labor Drugs

The risks of epidurals convert normal labor to a high-tech event. An IV must
be started to help counteract the tendency of epidurals to cause hypotension.
Electronic fetal monitoring is necessary because epidurals can cause fetal distress,
and the mother's vital signs must be closely monitored to warn of maternal adverse
reactions. If the needle or catheter pierces a blood vessel, which is easy to
do in pregnancy because blood vessels are enlarged, or the needle goes deeper
than the epidural space, convulsions, respiratory paralysis, and/or cardiac arrest
can occur. Tests are done to confirm proper placement before giving the full dosage,
but these are not completely preventative. Trained personnel, resuscitation equipment,
and medication must be immediately available.

In labor, epidurals increase the need for oxytocin, instrumental delivery, episiotomy,
and bladder catheterization. The first-time mother is more likely to have a cesarean.
Temporary postpartum complications include urinary incontinence, nerve injury
causing muscle weakness or abnormal sensation, and headache that can last for
days and is excruciatingly painful. Instrumental delivery and episiotomy increase
the probability of deep perineal tears. Backache and headache may become chronic.
In the newborn, epidurals may cause jaundice, and there may be adverse behavioral
effects.

Induction with Cytotec should never be attempted anywhere, most especially in
out-of-hospital settings. Incredibly, the American College of Obstetricians and
Gynecologists (ACOG) recently approved Cytotec induction in spite of lack of FDA
approval; in spite of a letter to doctors from Searle, the manufacturer of Cytotec,
imploring doctors not to use it for induction; in spite of lack of approval from
the Cochrane Library (the best scientific opinion); and in spite of the fact that
it is not approved or used for induction in any country in Western Europe.

ACOG quotes studies of Cytotec induction, none of which have a sufficient number
of research subjects, and consequently none of the studies quoted have sufficient
statistical power to detect small but potentially important risks such as uterine
hyperstimulation and uterine rupture. Furthermore, because published studies of
Cytotec induction have such wide methodological variability, meta-analysis is
impossible and the published attempts at such meta-analysis are seriously flawed....
Midwives should stay as far away as possible from such vigilante obstetrics--obstetricians
taking matters into their own hands while ignoring the recommendations of the
real judges.

PATHS TO BECOMING A MIDWIFE
IT'S NOT TOO LATE TO UPDATE!

We are quickly approaching the deadline for being able to accept updated school information.

Do you know of a program we overlooked in the last printing? A new program we may not be aware of? A new address of a school that has moved?

Remember, we include nurse-midwifery programs as well as direct-entry programs. We want this edition to be as complete as possible and would greatly appreciate the assistance of all of our E-News subscribers.

Please include, in the notes field, your connection to the midwifery program and how current this information is.

Midwifery Today's Online Forum

As a new doula, I'm curious how other doulas feel about suggesting/offering
herbs (teas to calm nausea, strengthen uterus, for overall health) to their pregnant
clients. To me, it feels like a natural thing to share my knowledge of herbs with
a mom-to-be. I consider a huge part of my role to be nurturing and empowering
her to learn about and take care of her body through this whole process. But I
also realize it may become sticky if my client is working with a doctor (or midwife)
who opposes the use of herbs or who doesn't communicate well with me, or medically
if there was some kind of condition that she didn't share with me, etc. I also
wonder about the legalities.

- Kiva

Go to our forums to share your thoughts and experience.

Question of the Week (repeated)

Q: Does anyone have experience with pregnancy coexisting
with kidney stones? My lady had kidney stones with her first pregnancy. There
has been a recurrence with her second pregnancy. Her urologist felt it necessary
to insert a nephrostomy tube to remain in for the duration of the pregnancy whereupon
she'll probably have lithrodisropy. Her pregnancy is normal and she wishes to
have a vaginal delivery. I wish to support her in this and am hoping there are
some of my sister midwives who've taken care of ladies like this.

- Anne Walters, CNM

====

Q: When you attend homebirths, what do you keep in
your kit ahead of time for those unexpected, middle-of-the-night calls? And what
is the most effective way to organize and carry your materials and supplies?

LUCK OF THE DRAW: We'll draw a name from among the respondents to the question
about birthkits--the winner will get a free copy of our latest Tricks of the Trade
book!

To qualify, **please include your email address in the body of your message**.

Switchboard

Know a strong woman? Helping empower one? If you haven't already done so, please
forward this issue of Midwifery Today E-News to one or two of your friends or
business associates. Thanks so much!

~*~*~*~*

I am a PhD student in prenatal and perinatal psychology. It seems these days
babies often get "dropped out of the picture" during birth till they're
in mom's arms. I am fascinated by this huge transition into the world that every
person makes and the power and enduring effects of that event. Because I don't
know of actual studies about this transition, yet we know babies are conscious
and aware at birth, I am looking for anecdotal information about baby-to-other
communication during birth: what was communicated, when, and how they communicated,
or how the communication was experienced by the recipient (i.e. visual image,
sensation, energy, a "knowing," a voice speaking, an emotion, or anything
else). I also want to know the reason for the communication: functional ("Tell
mom to squat so I can get unstuck") or related to emotion or something unresolved
that needed help. Please clarify the circumstances under which the communication
took place and where (home, prenatal visit at office, hospital, etc.) and if anyone
else was present and aware or unaware of the communication. Send a paragraph or
a page or so to me.

In response to the link between obstetric drug use and future substance abuse
in the baby: This possibility is explored in Michel Odent's video "Midwives,
Lullabies, and Mother Earth." A doctor presented a graph, presumably of his
data, showing how the baby's risk of later drug use jumped with each dose of meds
given.

- Melissa Schuppe
Virginia

====

For midwives interested in the long-term effects of drugs in the pre- and perinatal
period (including drugs in labour) I refer them to the writing of Stanislav Grof.
He refers to studies and his own work in Holotropic Breathwork on the effects
of birth trauma, drugs etc. in these and other of his books:

Psychology of the Future: Lessons from Modern Consciousness Studies, State
University of New York Press, 2000.

The Stormy Search for The Self, Thorsons, 1991 (with his wife Christina Grof).

I have found Grof's work and transpersonal psychology to be a very useful theoretical
framework in which to capture the essence of many birth experiences I have shared
with women and their babies.

I am an independent midwife in Canberra, Australia, and have been attending
homebirths here for 14 years. At present, homebirth/independent midwives are having
difficulty obtaining professional indemnity insurance so I have closed my practice
for a while.

- Emma Baldock

====

In regard to Claire's letter about the relationship between use of epidurals
in labor and later drug dependency in the children (Issue 3:47) and the letters
from Melissa Jonas and Natalie Bjorkland disputing this (Issue 3:48), I offer
the following research study reported in Epidemiology 2000;11:715-716.

Women who wish to lower their offspring's risk of drug abuse may decide to forego
some of their own drug use during labor and delivery, according to the results
of a prospective study. Dr. Karin Nyberg, of the University of Goteborg in Sweden,
and associates evaluated data collected on children born between 1959 and 1966.
Of the 693 subjects ages 18 to 27 years who were interviewed, 69 met DSM-III diagnostic
criteria for drug abuse and/or dependence on cocaine, hallucinogens, narcotics
or other drugs. Thirty-three non-drug abusing siblings served as controls.

Multiple doses of strong pain medication were used during labor preceding the
birth of 23% of the drug abusers and 6% of the controls. The researchers estimated
an unadjusted odds ratio of 4.7 for drug dependency in offspring whose mothers
received at least three doses of opiates or barbiturates within 10 hours of birth.
The occurrence of meconium-stained amniotic fluid was also associated with an
elevated risk of drug dependence, but this was confounded by prenatal drug exposure
in 5 of 17 cases. Other potential factors - prolonged labor, asphyxia, birth order,
and low birthweight - were similar among cases and controls. Dr. Nyberg and her
colleagues report that their results replicate previous findings in humans and
animals regarding prenatal exposure to high doses of medications at birth and
adult offspring's drug dependence.

Additionally, Beverly Lawrence Beech wrote to this topic in her paper "Drugs
in Labor: What Effects Do They Have Twenty Years Hence?"

"...In a well-designed case control study at the Karolinska Institute in
Stockholm in 1990, researchers compared children exposed to pain-relieving drugs
in labor with those who were not and discovered an increased risk of drug addiction
later in life (Jacobson et al., 1990). In 1988 they showed that when nitrous oxide
was given to the mother, the child was five and a half times more likely to become
an amphetamine addict than a brother or sister born to the same parents. In their
paper in the British Medical Journal (1990), patients who had died from opiate
addiction were compared with brothers and sisters; the researchers found that
if the mothers had been given opiates or barbiturates or larger doses of nitrous
oxide the risk of opiate addiction to the child in later life was increased 4.7
times. In a further study, researchers discovered that the risk of drug addiction
was related to the hospital in which they were born. In other words, the likelihood
of a child developing drug addiction in later life depended on the labor ward
policies of the hospital the mother chose for the birth, and I quote: "For
the amphetamine addicts, hospital of birth was found to be an important risk factor
even after controlling for residential area" (Nyberg, 1993). Jacobson and
Nyberg's research suggests that the use of opiates, barbiturates and nitrous oxide
in labor causes imprinting in the babies, and we are now reaping the whirlwind...."

Are we sure we can separate the effects of different pain-relieving drugs from
the effects of epidurals? Is it truly worth taking the risk? There should always
be a weighing of the risk-benefit factors. I believe there is a time when an epidural
is worth the risk - but I know they are much overused in the United States and
I have serious questions about the ethics of encouraging mothers to sign up in
advance for their epidurals during their childbirth education classes. I assist
at both hospital and homebirths where moms are supported through their labors
with no drugs whatsoever and have beautiful drug-free birth experiences! Of the
31 vaginal births I've attended, 24 moms have elected not to have an epidural
(or other drugs) - 77% - and 5 of the 7 who elected to have epidurals had labors
exceeding 18 hours. Someone said recently that you can't control birth, but you
can make an impact on how it will be by your thoughts and feelings. That's an
awesome responsibility for doulas and midwives!

I was homebirthed but I feel some of the symptoms Claire mentioned, i.e., "feeling
disconnected from their bodies, fuzzy thinking when under stress, feeling inadequate
and incapable of completing things they start" so I didn't give these symptoms
much credence and almost skipped the rest of her piece. In the end, I did like
what she said about making sure that the mother is informed of the possible risks
of any intervention. This is so important.

I had read about the risk of epidural and increased incidence of substance abuse
in an issue of Mothering magazine (No. 99 Mar/Apr 2000). The article by Beverley
Lawrence Beech cites studies that found an increase risk of substance abuse for
those babies delivered anesthetized [see above].

In another article in the same issue, Penny Simkin writes that an epidural puts
the baby at the risk of the following: bradycardia and hypoxia; tachycardia and
fever; subtle changes in newborn reflexes and neurobehavior, including suckling;
more difficulty in self-soothing or being consoled. She lists a few references
in her article.

- Colleen Morris

====

Regarding the tummy exercises mentioned in Issue 3:47 for diastasis of the rectus
abdominii: It is important to EXHALE your breath while flexing; that is, breathe
out when you pull yourself up into the crunch and flex the abdominal muscles.
The exercises are much more effective that way.

I was taught a low stress/high result version of the exercise: lying on back
on firm surface with hands behind head, pelvis tilted, then exhale and raise your
head and shoulders just a little while pulling your abdominal muscles in toward
the spine. Then inhale while relaxing. Do this several times per day for as many
repetitions as you find comfortable. Remembering an ounce of prevention, we might
add the exercises prenatally and before pregnancy, as well, along with our Kegels.

- Julia Swart

====

In reference to the techniques to turn breech [Issue 3:48], I believe they meant
to say the "Bladder 67 technique."

- Colleen Morris

====

For separated abdominal muscles: You may want to consider some herbs not only
to help your muscles heal but also to help you recover from your pregnancy. Astragalus
and Cordyceps would be great for you. A formula called Bu Zhong Yi Qi Tang (Ginseng
and Astragalus Combination - it usually doesn't contain ginseng) would probably
benefit your muscles and help your energy. Cordyceps is a great herb to help nourish
your primal energy, which women lose during childbirth. There are many herbs that
can do this.

It would be best if readers see a licensed acupuncturist or Chinese herbalist
for the herbs. As every person is individual, it is difficult to say what would
be the best dose. Also, every herb company will have different recommended doses
for their formulas so it is best to follow manufacturer suggested doses unless
otherwise advised. Doses are usually 6-12 grams boiled in 2 - 3 cups of water.

- Colleen Morris, L.Ac

====

To H. Henderson, who asked about paths to midwifery [Issue 3:48]:

It's wonderful that you want to be a midwife--there's no more rewarding job.
You will find it easier if you sort through some decisions about what kind of
midwifery you want to practice. Find midwives in your area and ask them if they
have time to chat with you about their own practice or even let you hang out with
them for a day and observe them on the job. Think about several issues about your
future job:

How important is your income level to you?

Do you want to practice homebirth, birth center birth, or in a hospital?

Do you want to be self-employed or be the employee with the perks and restrictions
that come with working for a hospital/clinic/doctor?

Is it important to be able to practice freely and legally in any state in
the US or are you likely to stay in California?

What kind of client are you drawn to--do you see yourself working with self-directed
women who want natural birth or working with low-income women on state insurance
who need a midwife to advocate for them in the hospital setting and help them
seek empowerment?

What is it that draws you to birth - what kind of images come up in your mind
when you imagine yourself as a midwife working with women and families?

Do you want to focus on pregnancy and birth or would you like to also do full-spectrum
gyn care involving birth control, STD testing, colposcopy of the cervix, well-women
care, menopausal care, etc.?

The short answer is, if you want to be a licensed homebirth midwife, you don't
need to be a nurse first. It might be difficult to let go of some of the medical
culture learned in nursing school once you study midwifery, yet nursing education
offers a lot of valuable training for healthcare. On the other hand, if you want
to be a certified nurse-midwife, you must complete your bachelors in nursing as
a prerequisite.

Best wishes to you on your journey.

- Kathleen Murray, CNM

====

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mtensubmit@midwiferytoday.com,
will be considered for inclusion. Letters sent to ANY OTHER email addresses will
not be considered.

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